title: Automated, real-time fresh gas flow recommendations alter isoflurane consumption during the maintenance phase of anesthesia in a simulator-based study.
abstract: BACKGROUND
  The Low Flow Wizard (LFW) provides real-time guidance for user optimization of fresh gas flow (FGF) settings during general inhaled anesthesia. The LFW can continuously inform users whether it determines their FGF to be too little, efficient, or too much, and its color-coded recommendations respond in real time to changes in FGF performed by users. Our study objective was to determine whether the LFW feature, as implemented in the Dräger Apollo workstation, alters FGF selection and thereby volatile anesthetic consumption without affecting patient care.
  
  
  METHODS
  To reduce potentially confounding variables, we used a human patient simulator that consumes and exhales volatile anesthetics. Standard monitoring was provided for the patient initially with invasive arterial blood pressure added after anesthetic induction. In this within-group study, each of 17 participants acted as his or her own control. Each participant was asked to anesthetize an identical simulated patient twice using a Dräger Apollo workstation, first with the LFW feature disabled and subsequently enabled. The volatile anesthetic was isoflurane. Both simulation runs were set up to have similar time durations for the different phases of anesthesia: induction, incision, and maintenance. Emergence was not simulated. The isoflurane vaporizer was weighed before and after each simulation run on a digital scale to verify total computed volatile liquid anesthetic consumption. In addition, the product of FGF (reported by the Apollo) times the isoflurane volumetric concentration (sampled by a multigas analyzer at the equivalent of the FGF hose for the Apollo) was integrated over time to obtain isoflurane consumption rate (on-the-fly anesthetic consumption rate measurement).
  
  
  RESULTS
  The maintenance isoflurane consumption rate and FGF were significantly lower with the LFW display enabled than without (P = 0.005). The mean reduction in FGF was 53.6% (95% confidence interval, 39.2%-67.9%). There was no significant difference in alveolar isoflurane concentration (P = 0.13 for differences <0.1%). The isoflurane consumption measurement closely matched the consumption measured via the digital scale.
  
  
  CONCLUSIONS
  Our data in a simulated anesthetic suggest that enabling the display of FGF efficiency data by the LFW results in a median percent reduction in volatile liquid anesthetic consumption rate of 53.2%. Since the lower limit of the 95% confidence interval for the median is 39.4%, this finding is likely to translate into cost savings and less waste anesthetic gas generated in the clinical setting and released into the atmosphere.
authors.affiliation: From the *Department of Anesthesiology, Center for Safety, Simulation and Advanced Learning Technologies, ‡Clinical and Translational Research Informatics Program, and §Office of Educational Affairs, College of Medicine, University of Florida, Gainesville, Florida. †Deceased on September 7, 2012.
authors.forename: Isaac
authors.initials: I
authors.lastname: Luria
authors.forename: Samsun
authors.initials: S
authors.lastname: Lampotang
authors.forename: Wilhelm
authors.initials: W
authors.lastname: Schwab
authors.forename: Lou Ann
authors.initials: LA
authors.lastname: Cooper
authors.forename: David
authors.initials: D
authors.lastname: Lizdas
authors.forename: Nikolaus
authors.initials: N
authors.lastname: Gravenstein
mesh_terms: D000328:Adult; D000368:Aged; D000769:Anesthesia, Inhalation / Q000295:instrumentation* / Q000379:methods*; D018685:Anesthetics, Inhalation / Q000008:administration & dosage*; D001331:Automation; D003198:Computer Simulation; D005260:Female; D006801:Humans; D007530:Isoflurane / Q000008:administration & dosage*; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000601:surgery; D010865:Pilot Projects; D015203:Reproducibility of Results; D012107:Research Design; D011795:Surveys and Questionnaires
chemical_list: D018685:Anesthetics, Inhalation; D007530:Isoflurane